OR Glaucoma Surgical Procedures Phaco Trabeculectomy and Phaco with Express Tube Shunt Insertion

South Hills Eye Associates Dr Donald Morris DO South Hills Eye Associates

Stating the Obvious

Review of Glaucoma Optic neuropathy with damage to the optic nerve Portions or all of the nerve are killed Usually associated with: high IOP visual field or OCT changes enlargement of optic nerve

Glaucoma Treatment First line of glaucoma treatment is medications When we are unable to adequately control IOP and stop damage to optic nerve with medications Move onto other alternatives for treatment

Glaucoma Treatment Alternatives are: Laser surgery Glaucoma filtering surgery with or without some form of tube shunt Viscocanulostomy Trabectome

Indications for Laser Surgery Unable to adequately control IOP using meds Patient who does not want to start meds When the laser lets us avoid a more invasive surgery

What They Really Teach Docs in Medical School

OR Glaucoma Surgical Procedures With failure of meds and laser, next option for control of IOP is surgery Two of the most common glaucoma procedures: Trabeculectomy Express Shunt

Trabeculectomy and Express Shunt Create a new drain in the eye Indication for glaucoma surgery Advanced glaucoma that is not controllable with medications or laser

Trabeculectomy In some cases trabeculectomy and express shunt are combined with cataract surgery Called phaco trab, phaco express trab or a glaucma combined surgery

Indications for Combined Surgery Visually significant cataract plus uncontrolled or poorly controlled glaucoma Worry about post cataract pressure spike in an eye with advanced disease Decrease or end need for glaucoma medications

Phaco Trab vs. Phaco Shunt Phaco trab is a one site procedure Phaco Express shunt is a two site procedure

Phaco Trab vs.. Phaco Express Benefits Not having to shift positions during the surgery Lower IOP post surgery, better control

Phaco Trab vs.. Phaco Express Negatives Higher Risk of hypotony With more outflow, higher risk of wound leak Higher risk of hyphema More inflammation and may scar closed faster than the express shunt

Trabeculectomy Procedure Peritomy is created on conjunctiva and retracted back toward the fornix 4 mm scleral flap is measured out and dissected back toward limbus Mitomycin C is placed over this area for 1 to 3 minutes

Trabeculectomy Cataract Procedure Anterior chamber is entered Capsulorhexis is created Lens nucleus is emulsified Cortex is removed Lens implant is placed

Trabeculectomy Procedure Full thickness sclerotomy is created either with a punch or blade Peripheral iridectomy is created Sutures are used to close scleral flap Sutures then close conjunctiva

Phaco Trab Surgery

Pumpkinotomy

Trabeculectomy vs Shunt Problem with trabeculectomy is: Surgery creates a hole in body that does not normally exist Body tries to scar closed this opening

Tube Shunt Solution is placing a metal or plastic tube instead of cutting hole in the sclera Tube stops sclerostomy from closing Any tube device is called a seton

Indications for Shunt Failed previous glaucoma surgery High risk for failure from excessive inflammation from uvietis or neovascular glaucoma Very advanced glaucoma

Express Tube Shunt Small metal shunt created for primary glaucoma surgery Takes place of sclerotomy No need for peripheral iridectomy Less inflammation and may be longer lasting than trab

Combined Cataract Express Shunt Visually significant cataract plus uncontrolled or poorly controlled glaucoma Worry about post cataract pressure spike Decrease or end need for glaucoma medications

Combined Cataract and Express Shunt This is a two site surgery I do cataract first, then move on to express shunt If complication with cat sx, shunt can be cancelled easily, no wound issues Personally find it easier than the phacotrab

Express Tube Shunt Procedure Peritomy is created and conjunctiva retracted back toward the fornix A four mm scleral flap is dissected toward the limbus Mitomycin C is placed over this area for 1 to 3 minutes

Express Tube Shunt Procedure 27 gauge needle makes tract into eye above iris Express shunt is inserted Scleral flap is closed with releasable or non releasable sutures Conjunctiva is closed

Combined Cataract and Tube Shunt Insertion Show video

Just The Words a Patient Wants to Hear

Combined Surgeries My preference is for really advanced glaucoma in the presence of a cataract to do the combined cataract trabeculectomy For less advanced glaucoma in the presence of a cataract, I prefer the phaco express shunt

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